Updating Patient Records in the EMR System

Overview
Keeping patient records up to date ensures safe and effective care. This article outlines how to enter progress notes, update medications, and upload documents in the EMR.

---

Step 1: Locate the Patient

1. Log into the EMR system
2. Use the search tool to find the correct patient
3. Open their profile and double-check the ID and name

---

Step 2: Add Progress Notes

1. Click the Progress Notes tab
2. Select Add New Note
3. Enter your update using approved clinical language
4. Assign your name, role, and timestamp
5. Click Save & Sign

Important: Never edit another clinician’s signed note. Use an addendum if needed.

---

Step 3: Update Medications

1. Navigate to the Medications tab
2. Review current prescriptions
3. Click + New Medication or Edit
4. Enter dose, frequency, and prescribing clinician
5. Save changes and confirm interactions (system will alert you if there’s a conflict)

---

Step 4: Upload a Document or Image

1. Go to the Documents section
2. Click Upload File
3. Select the document (e.g., referral letter, test result, consent form)
4. Add a short description and assign it to the appropriate category

---

Final Checks:

• Review all updates for accuracy
• Ensure you've signed any clinical notes
• Confirm that uploaded files are legible and correct

---

For help with editing errors or system issues, contact the IT Helpdesk via the Help Center.